Jeff Evans

CHANTILLY, VA. — Thyroid cancer patients who have received radioactive iodine ablation after thyroidectomy and who later have a negative whole body scan for thyroid cancer probably do not need to receive radioactive iodine therapy if their stimulated thyroglobulin levels stay below 10 ng/mL, R. Michael Tuttle, M.D., said at the annual meeting of the Mid-Atlantic Chapter of the American Association of Clinical Endocrinologists.

Whether a patient with a very low stimulated thyroglobulin level should be treated again with radioactive iodine (RAI) “is probably one of the most common phone calls I get from around the country,” said Dr. Tuttle of Memorial Sloan-Kettering Cancer Center, New York.

The way thyroid cancer is treated today is “so remarkably different now than it was 10 or 15 years ago,” he said, adding that the detection of persistent thyroid cancer has improved to the point where thyroglobulin (Tg) levels of 1, 0.5, or 0.2 ng/mL can be detected and 3-mm lymph nodes in the tracheal-esophageal groove can be seen with ultrasound in patients who were thought to be cured 20 years ago.

“I can't tell you the number of patients who leave my office mad at me because I've explained to them that I cannot cure their thyroid cancer. Their thyroglobulin level of 0.3 ng/mL is probably going to be there for awhile and taking out that 2-mm lymph node beside their recurrent laryngeal nerve is probably only going to help the surgeon and pathologist because they can bill and code for it, and it is unlikely to help our patient.”

About 80% of full body scans after repeat administration of therapeutic RAI appear to show some uptake by thyroid cells in the neck, but about 40% of these may be lung metastases, based on experience with all forms of thyroid cancer. If physicians give 100–150 mCi of RAI to patients with a high Tg level but a negative body scan, “you're very likely to find real disease,” Dr. Tuttle said, “and I think it's that finding of the lung metastasis that made us all do this.”

Rationale for RAI Changes Over Time

One rationale for using a therapeutic level of RAI when stimulated Tg levels remain high despite a negative diagnostic whole body scan was to localize the disease, not necessarily to treat it, Dr. Tuttle pointed out. Today's imaging modalities of helical CT and PET scans and neck ultrasounds can give the same information that RAI scanning would, without the possibility of side effects.

There is no evidence that repeat RAI treatment for patients who have a high stimulated Tg level after an initially negative whole body scan increases disease-specific or overall survival, Dr. Tuttle said.

Most clinicians would give another course of therapeutic RAI if the stimulated Tg level rose above 10 ng/mL, and most would not use repeat RAI if the stimulated level was below 2 ng/mL. RAI treatment for Tg levels of less than 2 ng/mL offers little potential benefit, while potentially causing complications, including damage to salivary glands, taste buds, and tear ducts. “We don't know what to do between 2 and 10,” Dr. Tuttle said.

Multiple RAI treatments appear to clear small-volume papillary thyroid cancer from pediatric to 30-year-old patients with positive lymph nodes by consistently decreasing stimulated Tg levels and clearing evidence of the tumor on CT scans and x-rays. These patients, who do not have distant metastases, are either cured or go into long-term remissions.

But older patients with thyroid cancer extending beyond the thyroid are more commonly seen than are younger patients with less aggressive, localized disease. Older patients may have a negative whole body scan and the same level of Tg as a younger patient, but the tumor is likely to be visible in the lungs on x-ray, CT, and PET scans. RAI will not help these patients if the lung lesions are poorly differentiated.

In a soon-to-be published study, Dr. Tuttle found that of about 400 thyroid cancer patients who received

Observe or Treat?

Another study involved 70 patients with thyroid cancer who had detectable Tg levels despite having a total thyroidectomy, RAI ablation, a negative whole body scan, and no structural evidence of disease. Of the 28 patients with a median stimulated Tg level of 9.5 ng/mL who were observed instead of being treated with RAI, 19 (68%) had an undetectable stimulated Tg level after 12 years of follow-up. Among the 42 patients with a median Tg level of 55 ng/mL who received RAI, only 12 (29%) had an undetectable stimulated Tg level after 7 years of follow-up (J. Clin. Endocrinol. Metab. 2001;86:4092–7).

Most patients who have undergone thyroidectomy and RAI ablation and have a negative whole body scan and a stimulated Tg level in the range of 2–10 ng/mL will see their Tg level decline to an undetectable level, so they probably should not be treated subsequently with RAI, Dr. Tuttle advised. It is likely that “if you do nothing, you are going to take credit for this thyroglobulin number going down over time all by itself.”

It is not necessary to treat patients with high Tg levels with two to three doses of RAI, he added. In a study of 17 patients with a negative initial whole body scan and an elevated Tg level, 16 patients had a positive scan after RAI therapy. During the course of three subsequent RAI doses, the percentage of patients with a decreasing Tg level increased from 81% to 90% to 100%, but the mean stimulated Tg level only decreased from 74 to 62 to 32 ng/mL, respectively (J. Clin. Endocrinol. Metab. 1995;80:1488–92).

Low Tg: RAI Probably Not Helpful

To determine if follow-up RAI therapy contributes to any changes in the stimulated Tg level of patients with an initial stimulated Tg level below 10 ng/mL, Dr. Tuttle conducted a study of 110 thyroid cancer patients who had Tg levels between 0.6 and 10 ng/mL and a negative whole body scan 1 year after receiving a total thyroidectomy and RAI ablation. At that point, 18 patients received repeat RAI therapy and 92 were observed.

After 1–2 years, stimulated Tg levels subsequently decreased in 71% and became undetectable in 29% of patients who had an initial stimulated Tg level between 0.6 and 2 ng/mL. In patients with an initial stimulated Tg level between 2 and 10 ng/mL, a significantly lower percentage of patients (3%) had an undetectable stimulated Tg level than those who had a decreased level (42%).

But among observed and RAI-treated patients with an initial stimulated Tg level between 2 and 10 ng/mL, there was no significant difference in the percentage of patients who had a reduction (40% vs. 45%, respectively), no change (12% vs. 18%), or an increase (48% vs. 37%) in their stimulated Tg level at follow-up.

CHANTILLY, VA. — Thyroid cancer patients who have received radioactive iodine ablation after thyroidectomy and who later have a negative whole body scan for thyroid cancer probably do not need to receive radioactive iodine therapy if their stimulated thyroglobulin levels stay below 10 ng/mL, R. Michael Tuttle, M.D., said at the annual meeting of the Mid-Atlantic Chapter of the American Association of Clinical Endocrinologists.

Whether a patient with a very low stimulated thyroglobulin level should be treated again with radioactive iodine (RAI) “is probably one of the most common phone calls I get from around the country,” said Dr. Tuttle of Memorial Sloan-Kettering Cancer Center, New York.

The way thyroid cancer is treated today is “so remarkably different now than it was 10 or 15 years ago,” he said, adding that the detection of persistent thyroid cancer has improved to the point where thyroglobulin (Tg) levels of 1, 0.5, or 0.2 ng/mL can be detected and 3-mm lymph nodes in the tracheal-esophageal groove can be seen with ultrasound in patients who were thought to be cured 20 years ago.

“I can't tell you the number of patients who leave my office mad at me because I've explained to them that I cannot cure their thyroid cancer. Their thyroglobulin level of 0.3 ng/mL is probably going to be there for awhile and taking out that 2-mm lymph node beside their recurrent laryngeal nerve is probably only going to help the surgeon and pathologist because they can bill and code for it, and it is unlikely to help our patient.”

About 80% of full body scans after repeat administration of therapeutic RAI appear to show some uptake by thyroid cells in the neck, but about 40% of these may be lung metastases, based on experience with all forms of thyroid cancer. If physicians give 100–150 mCi of RAI to patients with a high Tg level but a negative body scan, “you're very likely to find real disease,” Dr. Tuttle said, “and I think it's that finding of the lung metastasis that made us all do this.”

Rationale for RAI Changes Over Time

One rationale for using a therapeutic level of RAI when stimulated Tg levels remain high despite a negative diagnostic whole body scan was to localize the disease, not necessarily to treat it, Dr. Tuttle pointed out. Today's imaging modalities of helical CT and PET scans and neck ultrasounds can give the same information that RAI scanning would, without the possibility of side effects.

There is no evidence that repeat RAI treatment for patients who have a high stimulated Tg level after an initially negative whole body scan increases disease-specific or overall survival, Dr. Tuttle said.

Most clinicians would give another course of therapeutic RAI if the stimulated Tg level rose above 10 ng/mL, and most would not use repeat RAI if the stimulated level was below 2 ng/mL. RAI treatment for Tg levels of less than 2 ng/mL offers little potential benefit, while potentially causing complications, including damage to salivary glands, taste buds, and tear ducts. “We don't know what to do between 2 and 10,” Dr. Tuttle said.

Multiple RAI treatments appear to clear small-volume papillary thyroid cancer from pediatric to 30-year-old patients with positive lymph nodes by consistently decreasing stimulated Tg levels and clearing evidence of the tumor on CT scans and x-rays. These patients, who do not have distant metastases, are either cured or go into long-term remissions.

But older patients with thyroid cancer extending beyond the thyroid are more commonly seen than are younger patients with less aggressive, localized disease. Older patients may have a negative whole body scan and the same level of Tg as a younger patient, but the tumor is likely to be visible in the lungs on x-ray, CT, and PET scans. RAI will not help these patients if the lung lesions are poorly differentiated.

In a soon-to-be published study, Dr. Tuttle found that of about 400 thyroid cancer patients who received

Observe or Treat?

Another study involved 70 patients with thyroid cancer who had detectable Tg levels despite having a total thyroidectomy, RAI ablation, a negative whole body scan, and no structural evidence of disease. Of the 28 patients with a median stimulated Tg level of 9.5 ng/mL who were observed instead of being treated with RAI, 19 (68%) had an undetectable stimulated Tg level after 12 years of follow-up. Among the 42 patients with a median Tg level of 55 ng/mL who received RAI, only 12 (29%) had an undetectable stimulated Tg level after 7 years of follow-up (J. Clin. Endocrinol. Metab. 2001;86:4092–7).

Most patients who have undergone thyroidectomy and RAI ablation and have a negative whole body scan and a stimulated Tg level in the range of 2–10 ng/mL will see their Tg level decline to an undetectable level, so they probably should not be treated subsequently with RAI, Dr. Tuttle advised. It is likely that “if you do nothing, you are going to take credit for this thyroglobulin number going down over time all by itself.”

It is not necessary to treat patients with high Tg levels with two to three doses of RAI, he added. In a study of 17 patients with a negative initial whole body scan and an elevated Tg level, 16 patients had a positive scan after RAI therapy. During the course of three subsequent RAI doses, the percentage of patients with a decreasing Tg level increased from 81% to 90% to 100%, but the mean stimulated Tg level only decreased from 74 to 62 to 32 ng/mL, respectively (J. Clin. Endocrinol. Metab. 1995;80:1488–92).

Low Tg: RAI Probably Not Helpful

To determine if follow-up RAI therapy contributes to any changes in the stimulated Tg level of patients with an initial stimulated Tg level below 10 ng/mL, Dr. Tuttle conducted a study of 110 thyroid cancer patients who had Tg levels between 0.6 and 10 ng/mL and a negative whole body scan 1 year after receiving a total thyroidectomy and RAI ablation. At that point, 18 patients received repeat RAI therapy and 92 were observed.

After 1–2 years, stimulated Tg levels subsequently decreased in 71% and became undetectable in 29% of patients who had an initial stimulated Tg level between 0.6 and 2 ng/mL. In patients with an initial stimulated Tg level between 2 and 10 ng/mL, a significantly lower percentage of patients (3%) had an undetectable stimulated Tg level than those who had a decreased level (42%).

But among observed and RAI-treated patients with an initial stimulated Tg level between 2 and 10 ng/mL, there was no significant difference in the percentage of patients who had a reduction (40% vs. 45%, respectively), no change (12% vs. 18%), or an increase (48% vs. 37%) in their stimulated Tg level at follow-up.

CHANTILLY, VA. — Thyroid cancer patients who have received radioactive iodine ablation after thyroidectomy and who later have a negative whole body scan for thyroid cancer probably do not need to receive radioactive iodine therapy if their stimulated thyroglobulin levels stay below 10 ng/mL, R. Michael Tuttle, M.D., said at the annual meeting of the Mid-Atlantic Chapter of the American Association of Clinical Endocrinologists.

Whether a patient with a very low stimulated thyroglobulin level should be treated again with radioactive iodine (RAI) “is probably one of the most common phone calls I get from around the country,” said Dr. Tuttle of Memorial Sloan-Kettering Cancer Center, New York.

The way thyroid cancer is treated today is “so remarkably different now than it was 10 or 15 years ago,” he said, adding that the detection of persistent thyroid cancer has improved to the point where thyroglobulin (Tg) levels of 1, 0.5, or 0.2 ng/mL can be detected and 3-mm lymph nodes in the tracheal-esophageal groove can be seen with ultrasound in patients who were thought to be cured 20 years ago.

“I can't tell you the number of patients who leave my office mad at me because I've explained to them that I cannot cure their thyroid cancer. Their thyroglobulin level of 0.3 ng/mL is probably going to be there for awhile and taking out that 2-mm lymph node beside their recurrent laryngeal nerve is probably only going to help the surgeon and pathologist because they can bill and code for it, and it is unlikely to help our patient.”

About 80% of full body scans after repeat administration of therapeutic RAI appear to show some uptake by thyroid cells in the neck, but about 40% of these may be lung metastases, based on experience with all forms of thyroid cancer. If physicians give 100–150 mCi of RAI to patients with a high Tg level but a negative body scan, “you're very likely to find real disease,” Dr. Tuttle said, “and I think it's that finding of the lung metastasis that made us all do this.”

Rationale for RAI Changes Over Time

One rationale for using a therapeutic level of RAI when stimulated Tg levels remain high despite a negative diagnostic whole body scan was to localize the disease, not necessarily to treat it, Dr. Tuttle pointed out. Today's imaging modalities of helical CT and PET scans and neck ultrasounds can give the same information that RAI scanning would, without the possibility of side effects.

There is no evidence that repeat RAI treatment for patients who have a high stimulated Tg level after an initially negative whole body scan increases disease-specific or overall survival, Dr. Tuttle said.

Most clinicians would give another course of therapeutic RAI if the stimulated Tg level rose above 10 ng/mL, and most would not use repeat RAI if the stimulated level was below 2 ng/mL. RAI treatment for Tg levels of less than 2 ng/mL offers little potential benefit, while potentially causing complications, including damage to salivary glands, taste buds, and tear ducts. “We don't know what to do between 2 and 10,” Dr. Tuttle said.

Multiple RAI treatments appear to clear small-volume papillary thyroid cancer from pediatric to 30-year-old patients with positive lymph nodes by consistently decreasing stimulated Tg levels and clearing evidence of the tumor on CT scans and x-rays. These patients, who do not have distant metastases, are either cured or go into long-term remissions.

But older patients with thyroid cancer extending beyond the thyroid are more commonly seen than are younger patients with less aggressive, localized disease. Older patients may have a negative whole body scan and the same level of Tg as a younger patient, but the tumor is likely to be visible in the lungs on x-ray, CT, and PET scans. RAI will not help these patients if the lung lesions are poorly differentiated.

In a soon-to-be published study, Dr. Tuttle found that of about 400 thyroid cancer patients who received

Observe or Treat?

Another study involved 70 patients with thyroid cancer who had detectable Tg levels despite having a total thyroidectomy, RAI ablation, a negative whole body scan, and no structural evidence of disease. Of the 28 patients with a median stimulated Tg level of 9.5 ng/mL who were observed instead of being treated with RAI, 19 (68%) had an undetectable stimulated Tg level after 12 years of follow-up. Among the 42 patients with a median Tg level of 55 ng/mL who received RAI, only 12 (29%) had an undetectable stimulated Tg level after 7 years of follow-up (J. Clin. Endocrinol. Metab. 2001;86:4092–7).

Most patients who have undergone thyroidectomy and RAI ablation and have a negative whole body scan and a stimulated Tg level in the range of 2–10 ng/mL will see their Tg level decline to an undetectable level, so they probably should not be treated subsequently with RAI, Dr. Tuttle advised. It is likely that “if you do nothing, you are going to take credit for this thyroglobulin number going down over time all by itself.”

It is not necessary to treat patients with high Tg levels with two to three doses of RAI, he added. In a study of 17 patients with a negative initial whole body scan and an elevated Tg level, 16 patients had a positive scan after RAI therapy. During the course of three subsequent RAI doses, the percentage of patients with a decreasing Tg level increased from 81% to 90% to 100%, but the mean stimulated Tg level only decreased from 74 to 62 to 32 ng/mL, respectively (J. Clin. Endocrinol. Metab. 1995;80:1488–92).

Low Tg: RAI Probably Not Helpful

To determine if follow-up RAI therapy contributes to any changes in the stimulated Tg level of patients with an initial stimulated Tg level below 10 ng/mL, Dr. Tuttle conducted a study of 110 thyroid cancer patients who had Tg levels between 0.6 and 10 ng/mL and a negative whole body scan 1 year after receiving a total thyroidectomy and RAI ablation. At that point, 18 patients received repeat RAI therapy and 92 were observed.

After 1–2 years, stimulated Tg levels subsequently decreased in 71% and became undetectable in 29% of patients who had an initial stimulated Tg level between 0.6 and 2 ng/mL. In patients with an initial stimulated Tg level between 2 and 10 ng/mL, a significantly lower percentage of patients (3%) had an undetectable stimulated Tg level than those who had a decreased level (42%).

But among observed and RAI-treated patients with an initial stimulated Tg level between 2 and 10 ng/mL, there was no significant difference in the percentage of patients who had a reduction (40% vs. 45%, respectively), no change (12% vs. 18%), or an increase (48% vs. 37%) in their stimulated Tg level at follow-up.

STOCKHOLM – People who rely chiefly on interpersonal relationships for support into old age may have a high risk for depression when adverse life events disrupt those relationships, Carolyn Mazure, Ph.D., said at the 12th Congress of the International Psychogeriatric Association.

Researchers have known that younger adults who highly value a need for independence and control appear to have a higher risk for depression after adverse life events than do those who place great importance on interpersonal relationships.

The association between adverse life events and cognitive styles, however, appears to reverse itself in older age, said Dr. Mazure, professor of psychiatry at Yale University, New Haven, Conn.

Dr. Mazure and her colleagues have used the premises of Aaron T. Beck's cognitive theory of depression to predict late-life depression. His theory proposes that life events influence mood based on the meaning that an individual assigns to the life events and suggests that people use certain cognitive styles, or characteristic ways of looking at themselves in the world, to form stable belief systems that influence their interpretation of events.

The two cognitive styles that are inherent to the cognitive theory of depression are sociotropy and autonomy. Sociotropy is characterized by a high investment in interpersonal relationships, a desire to please others to avoid disapproval in order to secure attachments and build relationships, and a fear of separation and abandonment, she said

Autonomy focuses on a need for independence, control, and personal freedom to reduce the possibility of failure.

“If someone's cognitive style is particularly sociotropic, they are going to be more vulnerable to an adverse event that is interpersonal in nature, such as loss of a loved one.” Autonomous individuals, on the other hand, “are going to be more vulnerable to negative achievement events like a change in long-term residence,” as occurs when an individual is forced to leave his or her home of 40 years to go into an assisted-living facility, she said.

The interaction of sociotropy and autonomy with adverse life events has been studied extensively in U.S. samples of younger individuals, but models that explore the relationship of life stress in the context of cognitive styles generally have not been extended to older adults, she noted.

In one study, Dr. Mazure and her colleagues prospectively matched 42 outpatients who developed major depression at age 60 years or older with 42 nondepressed individuals from the community. Patients with a predominantly sociotropic cognitive style who had an adverse interpersonal life event were 11 times more likely to be diagnosed with depression than were patients without either characteristic. Those who had a predominantly autonomous cognitive style and suffered a negative achievement life event were six times more likely to be diagnosed with depression than were those without either characteristic (Am. J. Geriatr. Psychiatry 2002;10:297–304).

Medical illness and diminished physical functioning were associated with depression, but even in the context of these effects, the interaction between adverse life events and cognitive styles predicted the onset of depression.

The presence of a predominantly sociotropic cognitive style without an adverse life event made an individual three times more likely to be diagnosed with depression. A predominantly autonomous cognitive style without an adverse life event made individuals 55% less likely to be diagnosed with depression than were those without an autonomous cognitive style, which differs from findings in younger populations.

The investigators excluded patients with dementia or those who scored less than 24 on the Mini-Mental State Examination, as well as those with dysthymia, psychosis, or a history of substance abuse. The investigators asked patients about adverse life events that occurred in the 6 months prior to their diagnosis of depression and asked control individuals about life events in the 6 months prior to their interview.

In other studies that Dr. Mazure and her associates have performed using the same methods, they have found that the risk of depression in people with sociotropic cognitive styles stays the same over the course of life, while autonomy imparts a higher risk for depression at younger ages but gradually drops to contribute less risk for depression than does sociotropy in older people. The interaction of autonomy and negative achievement life events on the risk for depression follows the pattern for autonomy alone, but the interaction of sociotropy and adverse interpersonal life events increases the risk for depression as people age.

Questions to Consider

Dr. Mazure identified three areas for future research involving cognitive style and late-life depression:

▸ Can modifying cognitive styles reduce the risk for depression, especially when individuals are confronted with adverse life events?

▸ Are there gender differences in the interaction of cognitive styles and adverse life events?

▸ What age-specific approaches have the potential to be clinically meaningful in reducing the risk for depression?

STOCKHOLM – People who rely chiefly on interpersonal relationships for support into old age may have a high risk for depression when adverse life events disrupt those relationships, Carolyn Mazure, Ph.D., said at the 12th Congress of the International Psychogeriatric Association.

Researchers have known that younger adults who highly value a need for independence and control appear to have a higher risk for depression after adverse life events than do those who place great importance on interpersonal relationships.

The association between adverse life events and cognitive styles, however, appears to reverse itself in older age, said Dr. Mazure, professor of psychiatry at Yale University, New Haven, Conn.

Dr. Mazure and her colleagues have used the premises of Aaron T. Beck's cognitive theory of depression to predict late-life depression. His theory proposes that life events influence mood based on the meaning that an individual assigns to the life events and suggests that people use certain cognitive styles, or characteristic ways of looking at themselves in the world, to form stable belief systems that influence their interpretation of events.

The two cognitive styles that are inherent to the cognitive theory of depression are sociotropy and autonomy. Sociotropy is characterized by a high investment in interpersonal relationships, a desire to please others to avoid disapproval in order to secure attachments and build relationships, and a fear of separation and abandonment, she said

Autonomy focuses on a need for independence, control, and personal freedom to reduce the possibility of failure.

“If someone's cognitive style is particularly sociotropic, they are going to be more vulnerable to an adverse event that is interpersonal in nature, such as loss of a loved one.” Autonomous individuals, on the other hand, “are going to be more vulnerable to negative achievement events like a change in long-term residence,” as occurs when an individual is forced to leave his or her home of 40 years to go into an assisted-living facility, she said.

The interaction of sociotropy and autonomy with adverse life events has been studied extensively in U.S. samples of younger individuals, but models that explore the relationship of life stress in the context of cognitive styles generally have not been extended to older adults, she noted.

In one study, Dr. Mazure and her colleagues prospectively matched 42 outpatients who developed major depression at age 60 years or older with 42 nondepressed individuals from the community. Patients with a predominantly sociotropic cognitive style who had an adverse interpersonal life event were 11 times more likely to be diagnosed with depression than were patients without either characteristic. Those who had a predominantly autonomous cognitive style and suffered a negative achievement life event were six times more likely to be diagnosed with depression than were those without either characteristic (Am. J. Geriatr. Psychiatry 2002;10:297–304).

Medical illness and diminished physical functioning were associated with depression, but even in the context of these effects, the interaction between adverse life events and cognitive styles predicted the onset of depression.

The presence of a predominantly sociotropic cognitive style without an adverse life event made an individual three times more likely to be diagnosed with depression. A predominantly autonomous cognitive style without an adverse life event made individuals 55% less likely to be diagnosed with depression than were those without an autonomous cognitive style, which differs from findings in younger populations.

The investigators excluded patients with dementia or those who scored less than 24 on the Mini-Mental State Examination, as well as those with dysthymia, psychosis, or a history of substance abuse. The investigators asked patients about adverse life events that occurred in the 6 months prior to their diagnosis of depression and asked control individuals about life events in the 6 months prior to their interview.

In other studies that Dr. Mazure and her associates have performed using the same methods, they have found that the risk of depression in people with sociotropic cognitive styles stays the same over the course of life, while autonomy imparts a higher risk for depression at younger ages but gradually drops to contribute less risk for depression than does sociotropy in older people. The interaction of autonomy and negative achievement life events on the risk for depression follows the pattern for autonomy alone, but the interaction of sociotropy and adverse interpersonal life events increases the risk for depression as people age.

Questions to Consider

Dr. Mazure identified three areas for future research involving cognitive style and late-life depression:

▸ Can modifying cognitive styles reduce the risk for depression, especially when individuals are confronted with adverse life events?

▸ Are there gender differences in the interaction of cognitive styles and adverse life events?

▸ What age-specific approaches have the potential to be clinically meaningful in reducing the risk for depression?

STOCKHOLM – People who rely chiefly on interpersonal relationships for support into old age may have a high risk for depression when adverse life events disrupt those relationships, Carolyn Mazure, Ph.D., said at the 12th Congress of the International Psychogeriatric Association.

Researchers have known that younger adults who highly value a need for independence and control appear to have a higher risk for depression after adverse life events than do those who place great importance on interpersonal relationships.

The association between adverse life events and cognitive styles, however, appears to reverse itself in older age, said Dr. Mazure, professor of psychiatry at Yale University, New Haven, Conn.

Dr. Mazure and her colleagues have used the premises of Aaron T. Beck's cognitive theory of depression to predict late-life depression. His theory proposes that life events influence mood based on the meaning that an individual assigns to the life events and suggests that people use certain cognitive styles, or characteristic ways of looking at themselves in the world, to form stable belief systems that influence their interpretation of events.

The two cognitive styles that are inherent to the cognitive theory of depression are sociotropy and autonomy. Sociotropy is characterized by a high investment in interpersonal relationships, a desire to please others to avoid disapproval in order to secure attachments and build relationships, and a fear of separation and abandonment, she said

Autonomy focuses on a need for independence, control, and personal freedom to reduce the possibility of failure.

“If someone's cognitive style is particularly sociotropic, they are going to be more vulnerable to an adverse event that is interpersonal in nature, such as loss of a loved one.” Autonomous individuals, on the other hand, “are going to be more vulnerable to negative achievement events like a change in long-term residence,” as occurs when an individual is forced to leave his or her home of 40 years to go into an assisted-living facility, she said.

The interaction of sociotropy and autonomy with adverse life events has been studied extensively in U.S. samples of younger individuals, but models that explore the relationship of life stress in the context of cognitive styles generally have not been extended to older adults, she noted.

In one study, Dr. Mazure and her colleagues prospectively matched 42 outpatients who developed major depression at age 60 years or older with 42 nondepressed individuals from the community. Patients with a predominantly sociotropic cognitive style who had an adverse interpersonal life event were 11 times more likely to be diagnosed with depression than were patients without either characteristic. Those who had a predominantly autonomous cognitive style and suffered a negative achievement life event were six times more likely to be diagnosed with depression than were those without either characteristic (Am. J. Geriatr. Psychiatry 2002;10:297–304).

Medical illness and diminished physical functioning were associated with depression, but even in the context of these effects, the interaction between adverse life events and cognitive styles predicted the onset of depression.

The presence of a predominantly sociotropic cognitive style without an adverse life event made an individual three times more likely to be diagnosed with depression. A predominantly autonomous cognitive style without an adverse life event made individuals 55% less likely to be diagnosed with depression than were those without an autonomous cognitive style, which differs from findings in younger populations.

The investigators excluded patients with dementia or those who scored less than 24 on the Mini-Mental State Examination, as well as those with dysthymia, psychosis, or a history of substance abuse. The investigators asked patients about adverse life events that occurred in the 6 months prior to their diagnosis of depression and asked control individuals about life events in the 6 months prior to their interview.

In other studies that Dr. Mazure and her associates have performed using the same methods, they have found that the risk of depression in people with sociotropic cognitive styles stays the same over the course of life, while autonomy imparts a higher risk for depression at younger ages but gradually drops to contribute less risk for depression than does sociotropy in older people. The interaction of autonomy and negative achievement life events on the risk for depression follows the pattern for autonomy alone, but the interaction of sociotropy and adverse interpersonal life events increases the risk for depression as people age.

Questions to Consider

Dr. Mazure identified three areas for future research involving cognitive style and late-life depression:

▸ Can modifying cognitive styles reduce the risk for depression, especially when individuals are confronted with adverse life events?

▸ Are there gender differences in the interaction of cognitive styles and adverse life events?

▸ What age-specific approaches have the potential to be clinically meaningful in reducing the risk for depression?

BALTIMORE — Patients seeking leg vein treatment have the best outcome when clinicians selectively choose to treat varicosities and telangiectasias with sclerosants or lasers, Margaret A. Weiss, M.D., said at a meeting sponsored by the Skin Disease Education Foundation.

Learning the proper sclerotherapy technique is necessary for physicians who are going to offer laser treatment for leg veins because the leg vein treatment typically involves a combination approach, advised Dr. Weiss, of the department of dermatology at Johns Hopkins University, Baltimore.

“Offering a combination of treatments is helpful because treating reticular veins with lasers tends to be very painful,” she said. Laser treatments usually are more expensive and painful than sclerotherapy, and as a result, the overwhelming majority of her patients—about 95%—opt for sclerotherapy.

If a patient is interested in getting laser treatment for leg veins, Dr. Weiss said she often will give a laser treatment to a test area on the patient's leg and ask for the patient's feedback.

But before treating reticular veins and telangiectasias associated with incompetent great or short saphenous veins, endovenous techniques—which have replaced surgical stripping—must be used to cut off reflux from the saphenofemoral and saphenopopliteal junctions.

Ambulatory phlebectomy still is used for tributary veins about 4 mm or greater in size off the great saphenous vein, but it is gradually being replaced by foam sclerotherapy.

At the group practice she runs with her husband, Robert A. Weiss, M.D., in Hunt Valley, Md., Dr. Weiss usually treats reticular veins with about three to five treatments of foam sclerotherapy injections per area rather than treating them with lasers or intense pulsed light. Each treatment session is spaced in 3-week intervals.

The foam technique is inexpensive and increases the potency of any detergent solution such as Sotradecol (sodium tetradecyl sulfate injection), approved by the Food and Drug Administration, or polidocanol.

“I don't use polidocanol because it's not FDA approved,” she said.

Dr. Weiss uses the Tessari technique for making foamed sclerosant by connecting color-coded syringes—one with 0.1% or 0.2% Sotradecol and one with air—via a simple, latex-free, intravenous stopcock to agitate the solution. The mixture becomes a 3:1 or 4:1 ratio of air to solution. Dr. Weiss massages veins after each injection to increase the spread of the foamed sclerosant.

The foam acts on the principle that “by holding the solution in and dispersing it in theses bubbles, it adheres better to the vein wall,” she said. The bluish-green reticular vein will get lighter in color as the foam flows through it; the foam acts as a great visualization technique when using duplex ultrasound, she noted.

“We're really at the frontier of the expansion of this technique,” she said.

In many cases where Dr. Weiss now uses foamed Sotradecol at 0.1%, she said she used a 0.2% solution of Sotradecol in the past before the introduction of foam techniques. But because the foam technique doubles the potency of the sclerosant, the risk of hyperpigmentation increases.

Injection of foam Sotradecol into a telangiectasia results in a characteristic inflamed, elevated appearance.

Glycerine, a complex sugar classified as a toxic or corrosive agent, “is a great injectable for small telangiectasia as well as telangiectatic matting,” she said. Some pharmacies will compound a solution of glycerine at 72% in water. Dr. Weiss routinely uses glycerine to treat vessels less than 0.4 mm in diameter.

Treatment of leg veins with a laser is typically not as messy as it is with sclerosants since the appearance of veins becomes blurred and redder, without bleeding, whereas sclerotherapy injections may cause urticarial wheals, itching, and more postprocedure bruising and bleeding or oozing, Dr. Weiss said at the meeting.

Dr. Weiss said she would consider using lasers for leg veins for patients who have contraindications or a poor response to sclerotherapy, telangiectatic matting, or isolated, fine telangiectasia, which are often difficult to treat with sclerotherapy.

Overall, the best lasers for leg veins have a wavelength that is selectively absorbed by deoxyhemoglobin. Lasers with longer wavelengths penetrate deeper, and “that's important on the legs, since some of the inherent difficulties in treating leg veins as opposed to facial veins are that there is a much broader range of size and [the leg veins are] deeper under the skin,” she noted. This makes it harder to treat them without damaging the surrounding tissue.

High-fluence, long-pulse 1,064-nm lasers work well on leg veins because they target water and deoxyhemoglobin preferentially over melanin.

Smaller vessels need a shorter pulse duration, while larger vessels need a longer pulse duration of about 30–100 milliseconds, which “can get very painful even with the use of topical anesthetic creams,” she noted. Lasers used in treating leg veins have fluences in J/cm

To avoid damage to the epidermis, some lasers use cold gel, contact cooling, dynamic cooling spray, or cold blown air. Longer wavelength lasers, especially infrared, will cause less epidermal damage.

Intense pulsed light is most effective against superficial telangiectasias 0.2–0.3 mm in size in patients with Fitzpatrick skin types I to III, but the procedure is very technique sensitive and is dependent on the thickness and temperature of the gel, Dr. Weiss said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

BALTIMORE — Patients seeking leg vein treatment have the best outcome when clinicians selectively choose to treat varicosities and telangiectasias with sclerosants or lasers, Margaret A. Weiss, M.D., said at a meeting sponsored by the Skin Disease Education Foundation.

Learning the proper sclerotherapy technique is necessary for physicians who are going to offer laser treatment for leg veins because the leg vein treatment typically involves a combination approach, advised Dr. Weiss, of the department of dermatology at Johns Hopkins University, Baltimore.

“Offering a combination of treatments is helpful because treating reticular veins with lasers tends to be very painful,” she said. Laser treatments usually are more expensive and painful than sclerotherapy, and as a result, the overwhelming majority of her patients—about 95%—opt for sclerotherapy.

If a patient is interested in getting laser treatment for leg veins, Dr. Weiss said she often will give a laser treatment to a test area on the patient's leg and ask for the patient's feedback.

But before treating reticular veins and telangiectasias associated with incompetent great or short saphenous veins, endovenous techniques—which have replaced surgical stripping—must be used to cut off reflux from the saphenofemoral and saphenopopliteal junctions.

Ambulatory phlebectomy still is used for tributary veins about 4 mm or greater in size off the great saphenous vein, but it is gradually being replaced by foam sclerotherapy.

At the group practice she runs with her husband, Robert A. Weiss, M.D., in Hunt Valley, Md., Dr. Weiss usually treats reticular veins with about three to five treatments of foam sclerotherapy injections per area rather than treating them with lasers or intense pulsed light. Each treatment session is spaced in 3-week intervals.

The foam technique is inexpensive and increases the potency of any detergent solution such as Sotradecol (sodium tetradecyl sulfate injection), approved by the Food and Drug Administration, or polidocanol.

“I don't use polidocanol because it's not FDA approved,” she said.

Dr. Weiss uses the Tessari technique for making foamed sclerosant by connecting color-coded syringes—one with 0.1% or 0.2% Sotradecol and one with air—via a simple, latex-free, intravenous stopcock to agitate the solution. The mixture becomes a 3:1 or 4:1 ratio of air to solution. Dr. Weiss massages veins after each injection to increase the spread of the foamed sclerosant.

The foam acts on the principle that “by holding the solution in and dispersing it in theses bubbles, it adheres better to the vein wall,” she said. The bluish-green reticular vein will get lighter in color as the foam flows through it; the foam acts as a great visualization technique when using duplex ultrasound, she noted.

“We're really at the frontier of the expansion of this technique,” she said.

In many cases where Dr. Weiss now uses foamed Sotradecol at 0.1%, she said she used a 0.2% solution of Sotradecol in the past before the introduction of foam techniques. But because the foam technique doubles the potency of the sclerosant, the risk of hyperpigmentation increases.

Injection of foam Sotradecol into a telangiectasia results in a characteristic inflamed, elevated appearance.

Glycerine, a complex sugar classified as a toxic or corrosive agent, “is a great injectable for small telangiectasia as well as telangiectatic matting,” she said. Some pharmacies will compound a solution of glycerine at 72% in water. Dr. Weiss routinely uses glycerine to treat vessels less than 0.4 mm in diameter.

Treatment of leg veins with a laser is typically not as messy as it is with sclerosants since the appearance of veins becomes blurred and redder, without bleeding, whereas sclerotherapy injections may cause urticarial wheals, itching, and more postprocedure bruising and bleeding or oozing, Dr. Weiss said at the meeting.

Dr. Weiss said she would consider using lasers for leg veins for patients who have contraindications or a poor response to sclerotherapy, telangiectatic matting, or isolated, fine telangiectasia, which are often difficult to treat with sclerotherapy.

Overall, the best lasers for leg veins have a wavelength that is selectively absorbed by deoxyhemoglobin. Lasers with longer wavelengths penetrate deeper, and “that's important on the legs, since some of the inherent difficulties in treating leg veins as opposed to facial veins are that there is a much broader range of size and [the leg veins are] deeper under the skin,” she noted. This makes it harder to treat them without damaging the surrounding tissue.

High-fluence, long-pulse 1,064-nm lasers work well on leg veins because they target water and deoxyhemoglobin preferentially over melanin.

Smaller vessels need a shorter pulse duration, while larger vessels need a longer pulse duration of about 30–100 milliseconds, which “can get very painful even with the use of topical anesthetic creams,” she noted. Lasers used in treating leg veins have fluences in J/cm

To avoid damage to the epidermis, some lasers use cold gel, contact cooling, dynamic cooling spray, or cold blown air. Longer wavelength lasers, especially infrared, will cause less epidermal damage.

Intense pulsed light is most effective against superficial telangiectasias 0.2–0.3 mm in size in patients with Fitzpatrick skin types I to III, but the procedure is very technique sensitive and is dependent on the thickness and temperature of the gel, Dr. Weiss said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

BALTIMORE — Patients seeking leg vein treatment have the best outcome when clinicians selectively choose to treat varicosities and telangiectasias with sclerosants or lasers, Margaret A. Weiss, M.D., said at a meeting sponsored by the Skin Disease Education Foundation.

Learning the proper sclerotherapy technique is necessary for physicians who are going to offer laser treatment for leg veins because the leg vein treatment typically involves a combination approach, advised Dr. Weiss, of the department of dermatology at Johns Hopkins University, Baltimore.

“Offering a combination of treatments is helpful because treating reticular veins with lasers tends to be very painful,” she said. Laser treatments usually are more expensive and painful than sclerotherapy, and as a result, the overwhelming majority of her patients—about 95%—opt for sclerotherapy.

If a patient is interested in getting laser treatment for leg veins, Dr. Weiss said she often will give a laser treatment to a test area on the patient's leg and ask for the patient's feedback.

But before treating reticular veins and telangiectasias associated with incompetent great or short saphenous veins, endovenous techniques—which have replaced surgical stripping—must be used to cut off reflux from the saphenofemoral and saphenopopliteal junctions.

Ambulatory phlebectomy still is used for tributary veins about 4 mm or greater in size off the great saphenous vein, but it is gradually being replaced by foam sclerotherapy.

At the group practice she runs with her husband, Robert A. Weiss, M.D., in Hunt Valley, Md., Dr. Weiss usually treats reticular veins with about three to five treatments of foam sclerotherapy injections per area rather than treating them with lasers or intense pulsed light. Each treatment session is spaced in 3-week intervals.

The foam technique is inexpensive and increases the potency of any detergent solution such as Sotradecol (sodium tetradecyl sulfate injection), approved by the Food and Drug Administration, or polidocanol.

“I don't use polidocanol because it's not FDA approved,” she said.

Dr. Weiss uses the Tessari technique for making foamed sclerosant by connecting color-coded syringes—one with 0.1% or 0.2% Sotradecol and one with air—via a simple, latex-free, intravenous stopcock to agitate the solution. The mixture becomes a 3:1 or 4:1 ratio of air to solution. Dr. Weiss massages veins after each injection to increase the spread of the foamed sclerosant.

The foam acts on the principle that “by holding the solution in and dispersing it in theses bubbles, it adheres better to the vein wall,” she said. The bluish-green reticular vein will get lighter in color as the foam flows through it; the foam acts as a great visualization technique when using duplex ultrasound, she noted.

“We're really at the frontier of the expansion of this technique,” she said.

In many cases where Dr. Weiss now uses foamed Sotradecol at 0.1%, she said she used a 0.2% solution of Sotradecol in the past before the introduction of foam techniques. But because the foam technique doubles the potency of the sclerosant, the risk of hyperpigmentation increases.

Injection of foam Sotradecol into a telangiectasia results in a characteristic inflamed, elevated appearance.

Glycerine, a complex sugar classified as a toxic or corrosive agent, “is a great injectable for small telangiectasia as well as telangiectatic matting,” she said. Some pharmacies will compound a solution of glycerine at 72% in water. Dr. Weiss routinely uses glycerine to treat vessels less than 0.4 mm in diameter.

Treatment of leg veins with a laser is typically not as messy as it is with sclerosants since the appearance of veins becomes blurred and redder, without bleeding, whereas sclerotherapy injections may cause urticarial wheals, itching, and more postprocedure bruising and bleeding or oozing, Dr. Weiss said at the meeting.

Dr. Weiss said she would consider using lasers for leg veins for patients who have contraindications or a poor response to sclerotherapy, telangiectatic matting, or isolated, fine telangiectasia, which are often difficult to treat with sclerotherapy.

Overall, the best lasers for leg veins have a wavelength that is selectively absorbed by deoxyhemoglobin. Lasers with longer wavelengths penetrate deeper, and “that's important on the legs, since some of the inherent difficulties in treating leg veins as opposed to facial veins are that there is a much broader range of size and [the leg veins are] deeper under the skin,” she noted. This makes it harder to treat them without damaging the surrounding tissue.

High-fluence, long-pulse 1,064-nm lasers work well on leg veins because they target water and deoxyhemoglobin preferentially over melanin.

Smaller vessels need a shorter pulse duration, while larger vessels need a longer pulse duration of about 30–100 milliseconds, which “can get very painful even with the use of topical anesthetic creams,” she noted. Lasers used in treating leg veins have fluences in J/cm

To avoid damage to the epidermis, some lasers use cold gel, contact cooling, dynamic cooling spray, or cold blown air. Longer wavelength lasers, especially infrared, will cause less epidermal damage.

Intense pulsed light is most effective against superficial telangiectasias 0.2–0.3 mm in size in patients with Fitzpatrick skin types I to III, but the procedure is very technique sensitive and is dependent on the thickness and temperature of the gel, Dr. Weiss said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

Intensity of exposure to tobacco smoke appears to be associated with the rate of metabolic syndrome in a dose-response relationship in adolescents, according to a study in the cross-sectional third National Health and Nutrition Examination Survey.

The study is the first of its kind to associate smoking with metabolic syndrome by using a biologic marker of smoking—serum levels of the nicotine metabolite cotinine—and exposure to environmental tobacco smoke in adolescents, reported Michael Weitzman, M.D., of the University of Rochester (N.Y.) and his colleagues (Circulation 2005;112:862–9).

In the 1988–1994 survey of 2,273 adolescents aged 12–19 years, exposure to environmental tobacco smoke and active smoking were independently associated with nearly fivefold and more than sixfold higher odds of developing metabolic syndrome, respectively, after adjustment for gender, age, race or ethnicity, poverty status, region, and parental history of diabetes or heart attack.

The investigators obtained similar results when they restricted their analysis to individuals with a body mass index at the 85th percentile or higher (those who are overweight and at risk for overweight).

Of 664 adolescents overweight or at risk for overweight, metabolic syndrome occurred at a rate of 5.6% in individuals who were not exposed to tobacco smoke; 19.6% in those exposed to environmental or secondhand smoke; and 23.6% in active smokers. The increase in the rate of metabolic syndrome in adolescents followed a significant trend from those who were not exposed to tobacco smoke, through the lowest to highest level of exposure to environmental tobacco smoke, up to active smokers.

The criteria for metabolic syndrome consisted of a triglyceride level of 110 mg/dL or higher, an HDL cholesterol level of 40 mg/dL or lower, a waist circumference at the 90th percentile or higher, blood pressure in the 90th percentile or higher, and a fasting plasma glucose level of 100 mg/dL or higher.

Their report cannot “conclusively establish an etiologic role for tobacco smoke in the development of the metabolic syndrome in youth,” the investigators noted, adding that such a link is plausible in that “evidence in studies of children suggests that insulin resistance mediates the deleterious effects of excess adiposity on blood pressure and lipids in the metabolic syndrome” and “smoking is associated with increased insulin resistance in adults.”

Intensity of exposure to tobacco smoke appears to be associated with the rate of metabolic syndrome in a dose-response relationship in adolescents, according to a study in the cross-sectional third National Health and Nutrition Examination Survey.

The study is the first of its kind to associate smoking with metabolic syndrome by using a biologic marker of smoking—serum levels of the nicotine metabolite cotinine—and exposure to environmental tobacco smoke in adolescents, reported Michael Weitzman, M.D., of the University of Rochester (N.Y.) and his colleagues (Circulation 2005;112:862–9).

In the 1988–1994 survey of 2,273 adolescents aged 12–19 years, exposure to environmental tobacco smoke and active smoking were independently associated with nearly fivefold and more than sixfold higher odds of developing metabolic syndrome, respectively, after adjustment for gender, age, race or ethnicity, poverty status, region, and parental history of diabetes or heart attack.

The investigators obtained similar results when they restricted their analysis to individuals with a body mass index at the 85th percentile or higher (those who are overweight and at risk for overweight).

Of 664 adolescents overweight or at risk for overweight, metabolic syndrome occurred at a rate of 5.6% in individuals who were not exposed to tobacco smoke; 19.6% in those exposed to environmental or secondhand smoke; and 23.6% in active smokers. The increase in the rate of metabolic syndrome in adolescents followed a significant trend from those who were not exposed to tobacco smoke, through the lowest to highest level of exposure to environmental tobacco smoke, up to active smokers.

The criteria for metabolic syndrome consisted of a triglyceride level of 110 mg/dL or higher, an HDL cholesterol level of 40 mg/dL or lower, a waist circumference at the 90th percentile or higher, blood pressure in the 90th percentile or higher, and a fasting plasma glucose level of 100 mg/dL or higher.

Their report cannot “conclusively establish an etiologic role for tobacco smoke in the development of the metabolic syndrome in youth,” the investigators noted, adding that such a link is plausible in that “evidence in studies of children suggests that insulin resistance mediates the deleterious effects of excess adiposity on blood pressure and lipids in the metabolic syndrome” and “smoking is associated with increased insulin resistance in adults.”

Intensity of exposure to tobacco smoke appears to be associated with the rate of metabolic syndrome in a dose-response relationship in adolescents, according to a study in the cross-sectional third National Health and Nutrition Examination Survey.

The study is the first of its kind to associate smoking with metabolic syndrome by using a biologic marker of smoking—serum levels of the nicotine metabolite cotinine—and exposure to environmental tobacco smoke in adolescents, reported Michael Weitzman, M.D., of the University of Rochester (N.Y.) and his colleagues (Circulation 2005;112:862–9).

In the 1988–1994 survey of 2,273 adolescents aged 12–19 years, exposure to environmental tobacco smoke and active smoking were independently associated with nearly fivefold and more than sixfold higher odds of developing metabolic syndrome, respectively, after adjustment for gender, age, race or ethnicity, poverty status, region, and parental history of diabetes or heart attack.

The investigators obtained similar results when they restricted their analysis to individuals with a body mass index at the 85th percentile or higher (those who are overweight and at risk for overweight).

Of 664 adolescents overweight or at risk for overweight, metabolic syndrome occurred at a rate of 5.6% in individuals who were not exposed to tobacco smoke; 19.6% in those exposed to environmental or secondhand smoke; and 23.6% in active smokers. The increase in the rate of metabolic syndrome in adolescents followed a significant trend from those who were not exposed to tobacco smoke, through the lowest to highest level of exposure to environmental tobacco smoke, up to active smokers.

The criteria for metabolic syndrome consisted of a triglyceride level of 110 mg/dL or higher, an HDL cholesterol level of 40 mg/dL or lower, a waist circumference at the 90th percentile or higher, blood pressure in the 90th percentile or higher, and a fasting plasma glucose level of 100 mg/dL or higher.

Their report cannot “conclusively establish an etiologic role for tobacco smoke in the development of the metabolic syndrome in youth,” the investigators noted, adding that such a link is plausible in that “evidence in studies of children suggests that insulin resistance mediates the deleterious effects of excess adiposity on blood pressure and lipids in the metabolic syndrome” and “smoking is associated with increased insulin resistance in adults.”

STOCKHOLM — Individuals who carry the apolipoprotein E ϵ4 allele that increases the risk of developing Alzheimer's disease may lower their risk to that of a noncarrier through regular exercise, moderate fat intake, and low alcohol consumption, reported Tiia Ngandu at the 12th Congress of the International Psychogeriatric Association.

Ms. Ngandu and her associates studied 1,449 Finnish people who participated in the longitudinal, population-based Cardiovascular Risk Factors, Aging, and Dementia study (CAIDE) in 1972, 1977, 1982, or 1987. After an average follow-up of 21 years, the participants were aged 65–79 years when they were reexamined in 1998.

Based on questions answered at midlife, active individuals (exercised at least twice per week) who carried the ϵ4 allele of apolipoprotein E (apo E) had a significantly lower likelihood of developing Alzheimer's disease (AD) than sedentary carriers, said Ms. Ngandu, a doctoral student at the Aging Research Center at the Karolinska Institute, Stockholm.

Intake of polyunsaturated fatty acids did not alter the odds of developing AD in carriers, but high intake of saturated fatty acids was associated with significantly greater odds of AD in carriers, compared with a low intake.

Apo E ϵ4 carriers who frequently consumed alcohol had a significantly higher likelihood of developing AD than carriers who drank infrequently or never.

None of the lifestyle factors reduced the risk of AD in noncarriers, she noted.

“Carriers seem more vulnerable to various environmental effects,” she said.

People with a parent with late-onset Alzheimer's disease may undergo genotyping for apo E. A positive finding is not diagnostic of Alzheimer's disease, even in a symptomatic patient. The test also is done in some patients with both high cholesterol and elevated triglycerides to determine whether the patient's lipid disorder has a genetic component.

STOCKHOLM — Individuals who carry the apolipoprotein E ϵ4 allele that increases the risk of developing Alzheimer's disease may lower their risk to that of a noncarrier through regular exercise, moderate fat intake, and low alcohol consumption, reported Tiia Ngandu at the 12th Congress of the International Psychogeriatric Association.

Ms. Ngandu and her associates studied 1,449 Finnish people who participated in the longitudinal, population-based Cardiovascular Risk Factors, Aging, and Dementia study (CAIDE) in 1972, 1977, 1982, or 1987. After an average follow-up of 21 years, the participants were aged 65–79 years when they were reexamined in 1998.

Based on questions answered at midlife, active individuals (exercised at least twice per week) who carried the ϵ4 allele of apolipoprotein E (apo E) had a significantly lower likelihood of developing Alzheimer's disease (AD) than sedentary carriers, said Ms. Ngandu, a doctoral student at the Aging Research Center at the Karolinska Institute, Stockholm.

Intake of polyunsaturated fatty acids did not alter the odds of developing AD in carriers, but high intake of saturated fatty acids was associated with significantly greater odds of AD in carriers, compared with a low intake.

Apo E ϵ4 carriers who frequently consumed alcohol had a significantly higher likelihood of developing AD than carriers who drank infrequently or never.

None of the lifestyle factors reduced the risk of AD in noncarriers, she noted.

“Carriers seem more vulnerable to various environmental effects,” she said.

People with a parent with late-onset Alzheimer's disease may undergo genotyping for apo E. A positive finding is not diagnostic of Alzheimer's disease, even in a symptomatic patient. The test also is done in some patients with both high cholesterol and elevated triglycerides to determine whether the patient's lipid disorder has a genetic component.

STOCKHOLM — Individuals who carry the apolipoprotein E ϵ4 allele that increases the risk of developing Alzheimer's disease may lower their risk to that of a noncarrier through regular exercise, moderate fat intake, and low alcohol consumption, reported Tiia Ngandu at the 12th Congress of the International Psychogeriatric Association.

Ms. Ngandu and her associates studied 1,449 Finnish people who participated in the longitudinal, population-based Cardiovascular Risk Factors, Aging, and Dementia study (CAIDE) in 1972, 1977, 1982, or 1987. After an average follow-up of 21 years, the participants were aged 65–79 years when they were reexamined in 1998.

Based on questions answered at midlife, active individuals (exercised at least twice per week) who carried the ϵ4 allele of apolipoprotein E (apo E) had a significantly lower likelihood of developing Alzheimer's disease (AD) than sedentary carriers, said Ms. Ngandu, a doctoral student at the Aging Research Center at the Karolinska Institute, Stockholm.

Intake of polyunsaturated fatty acids did not alter the odds of developing AD in carriers, but high intake of saturated fatty acids was associated with significantly greater odds of AD in carriers, compared with a low intake.

Apo E ϵ4 carriers who frequently consumed alcohol had a significantly higher likelihood of developing AD than carriers who drank infrequently or never.

None of the lifestyle factors reduced the risk of AD in noncarriers, she noted.

“Carriers seem more vulnerable to various environmental effects,” she said.

People with a parent with late-onset Alzheimer's disease may undergo genotyping for apo E. A positive finding is not diagnostic of Alzheimer's disease, even in a symptomatic patient. The test also is done in some patients with both high cholesterol and elevated triglycerides to determine whether the patient's lipid disorder has a genetic component.

WASHINGTON — Detailed ethical codes from professional organizations would help set a clearer path for health professionals to follow on national security-related issues.

That sentiment was expressed by several experts at a recent panel discussion on the medical ethics of military medical professionals' interrogations sponsored by the Center for American Progress.

Active and retired medical officers also think the policy that guides medical personnel in these matters needs to be clarified, Stephen Xenakis, M.D., said at the meeting. Dr. Xenakis, formerly the commanding general of the Southeast Regional Army Medical Command, is now the director of child and adolescent psychiatry at the Psychiatric Institute of Washington.

At Guantanamo Bay and Abu Ghraib prison, mental health professionals, such as psychiatrists and psychologists, are known to have observed interrogations, provided interrogators with the medical records of detainees, and in some cases, developed individualized interrogation plans or provided advice on how best to conduct an interrogation.

These acts have been made public by various documents obtained through military sources, Freedom of Information Act requests, declassification, interviews with witnesses, or testimony (N. Engl. J. Med. 2005;352:3–6; N. Engl. J. Med. 2005;353:6–8).

“The legal barriers are likely to be crossed long before detainees' mental or physical health is implicated, particularly when those detainees are protected by the Geneva Conventions,” Jonathan H. Marks, said at the panel discussion.

“Medical personnel, if they stand by, will be complicit in violations of the Geneva Conventions if they approve of these techniques or fail to intervene,” said Mr. Marks, a barrister who is currently a fellow at Georgetown University Law Center, Washington.

The civilian leadership at the Pentagon has argued that when physicians and other health professionals serve in the interrogation process and other nontherapeutic roles, they are not acting as physicians or health professionals, and medical ethics do not apply, noted M. Gregg Bloche, M.D., a member of the panel. “This is a deeply disturbing argument with little or no precedent elsewhere,” said Dr. Bloche, a law professor at Georgetown.

In previous operations, the Army has worked on the principle of very detailed, exhaustive training for its medical personnel, Dr. Xenakis noted. The current operations lack “clear guidance for what one does when one confronts scenarios of large volumes of detainees who have recently been apprehended, how they will be triaged, how they will be held, how they will be interrogated.”

Dr. Xenakis said he would like to see the American Medical Association and the American Psychiatric Association define the guidance policy on what military medical personnel should and should not be expected to do. Such statements would be affirming to the internal principles and ethics of physicians and other health professionals, he added.

New absolute standards must limit the physician's role in the military to the doctor-patient relationship in which a physician cannot participate in interrogations, he suggested.

Indeed, the APA is in the process of hammering out a position on the role that mental health professionals should play in the interrogation of detainees at Guantanamo Bay and other prison sites around the world, Paul S. Appelbaum, M.D., told this newspaper.

Representatives from several key APA committees met this fall to develop a proposed position. That proposal will then go through a formal chain of approvals, including the APA assembly and the board of trustees, said Dr. Appelbaum, chairman of the APA's Council on Psychiatry and the Law and a former president of the organization.

However, the debate about this issue also needs to take place in the public domain, Edmund G. Howe, M.D., said in an interview.

Dr. Howe, professor of psychiatry and director of the program in ethics at the Uniformed Services University of the Health Sciences, Bethesda, Md., said he would like to see a code in print representing as many military and civilian views as possible.

Codes of ethics “can accomplish all sorts of things by giving general guidelines that most persons find useful and maybe [help them] do better than they would without those guidelines.

The question here is, what are the pluses and minuses of any group's spelling out its particular moral priorities?” Dr. Howe said.

It would be problematic for the military to articulate its moral biases and perspectives and then impose them without outside input, Dr. Howe said. He added that while that might be obvious, it's less obvious that any organization—whether it be the AMA or the APA—also has its own biases and perspectives.

For example, why shouldn't the American Bar Association or a patients' association, for that matter, have its own code? “Is medical expertise tantamount to ethical expertise? No,” Dr. Howe said.

When patients sacrifice their money and personal privacy so that medical students can perform physical exams and develop their skills, society has implicit expectations about what the students will do with the knowledge they gain from encounters with patients. Some would say that there's an implicit promise from the doctor—like the Hippocratic Oath—when the patient is making those sacrifices in order for the doctor to do good. Then the question is, “Does doing good include getting involved in interrogations?” Dr. Howe asked.

Even if society is willing, in theory, to say that it will make these sacrifices so that students can be trained to become doctors to heal medical and psychiatric problems and also to save lives by participating in some way in interrogations, “it does not necessarily mean that it should fly, even if most psychiatrists would go along with it. Additional ethical assessment is necessary,” he said.

Contrary to the position taken by key experts, the American Psychological Association's approach to this issue appears to be different. That organization's Presidential Task Force states that psychologists can “serve in the role of supporting an interrogation” and make use of confidential information in medical records of detainees or prisoners to advise interrogators, as long as it is not used to the detriment of the individual's safety and well-being.

The task force's report does warn psychologists working in a national security-related setting that they should “clarify their role in situations where individuals may have an incorrect impression that psychologists are serving in a health care provider role.”

In addition, psychologists should refrain from mixing potentially inconsistent roles with the same individual, in those cases when the roles “could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness. … or otherwise risk exploitation or harm to the person with whom the professional relationship exists.”

In the panel discussion, Dr. Bloche argued that the American Psychological Association's statement “allows for a wholesale breach of confidentiality.”

However, Stephen Behnke, director of ethics for the American Psychological Association, said in an interview that there should be an absolute barrier between work that is treatment related and work related to interrogations.

“Under no circumstances should the two be mixed,” Mr. Behnke said.

He pointed out that his association had provided its task force report to the U.S. government and that training is needed.

But overcoming the obstacle of health care providers serving as consultants to interrogators by creating separate schools or training for each type, “doesn't really address what the real problems are,” Dr. Howe said.

The real problems are determining how humans should treat other humans—and who should decide, he asserted.

WASHINGTON — Detailed ethical codes from professional organizations would help set a clearer path for health professionals to follow on national security-related issues.

That sentiment was expressed by several experts at a recent panel discussion on the medical ethics of military medical professionals' interrogations sponsored by the Center for American Progress.

Active and retired medical officers also think the policy that guides medical personnel in these matters needs to be clarified, Stephen Xenakis, M.D., said at the meeting. Dr. Xenakis, formerly the commanding general of the Southeast Regional Army Medical Command, is now the director of child and adolescent psychiatry at the Psychiatric Institute of Washington.

At Guantanamo Bay and Abu Ghraib prison, mental health professionals, such as psychiatrists and psychologists, are known to have observed interrogations, provided interrogators with the medical records of detainees, and in some cases, developed individualized interrogation plans or provided advice on how best to conduct an interrogation.

These acts have been made public by various documents obtained through military sources, Freedom of Information Act requests, declassification, interviews with witnesses, or testimony (N. Engl. J. Med. 2005;352:3–6; N. Engl. J. Med. 2005;353:6–8).

“The legal barriers are likely to be crossed long before detainees' mental or physical health is implicated, particularly when those detainees are protected by the Geneva Conventions,” Jonathan H. Marks, said at the panel discussion.

“Medical personnel, if they stand by, will be complicit in violations of the Geneva Conventions if they approve of these techniques or fail to intervene,” said Mr. Marks, a barrister who is currently a fellow at Georgetown University Law Center, Washington.

The civilian leadership at the Pentagon has argued that when physicians and other health professionals serve in the interrogation process and other nontherapeutic roles, they are not acting as physicians or health professionals, and medical ethics do not apply, noted M. Gregg Bloche, M.D., a member of the panel. “This is a deeply disturbing argument with little or no precedent elsewhere,” said Dr. Bloche, a law professor at Georgetown.

In previous operations, the Army has worked on the principle of very detailed, exhaustive training for its medical personnel, Dr. Xenakis noted. The current operations lack “clear guidance for what one does when one confronts scenarios of large volumes of detainees who have recently been apprehended, how they will be triaged, how they will be held, how they will be interrogated.”

Dr. Xenakis said he would like to see the American Medical Association and the American Psychiatric Association define the guidance policy on what military medical personnel should and should not be expected to do. Such statements would be affirming to the internal principles and ethics of physicians and other health professionals, he added.

New absolute standards must limit the physician's role in the military to the doctor-patient relationship in which a physician cannot participate in interrogations, he suggested.

Indeed, the APA is in the process of hammering out a position on the role that mental health professionals should play in the interrogation of detainees at Guantanamo Bay and other prison sites around the world, Paul S. Appelbaum, M.D., told this newspaper.

Representatives from several key APA committees met this fall to develop a proposed position. That proposal will then go through a formal chain of approvals, including the APA assembly and the board of trustees, said Dr. Appelbaum, chairman of the APA's Council on Psychiatry and the Law and a former president of the organization.

However, the debate about this issue also needs to take place in the public domain, Edmund G. Howe, M.D., said in an interview.

Dr. Howe, professor of psychiatry and director of the program in ethics at the Uniformed Services University of the Health Sciences, Bethesda, Md., said he would like to see a code in print representing as many military and civilian views as possible.

Codes of ethics “can accomplish all sorts of things by giving general guidelines that most persons find useful and maybe [help them] do better than they would without those guidelines.

The question here is, what are the pluses and minuses of any group's spelling out its particular moral priorities?” Dr. Howe said.

It would be problematic for the military to articulate its moral biases and perspectives and then impose them without outside input, Dr. Howe said. He added that while that might be obvious, it's less obvious that any organization—whether it be the AMA or the APA—also has its own biases and perspectives.

For example, why shouldn't the American Bar Association or a patients' association, for that matter, have its own code? “Is medical expertise tantamount to ethical expertise? No,” Dr. Howe said.

When patients sacrifice their money and personal privacy so that medical students can perform physical exams and develop their skills, society has implicit expectations about what the students will do with the knowledge they gain from encounters with patients. Some would say that there's an implicit promise from the doctor—like the Hippocratic Oath—when the patient is making those sacrifices in order for the doctor to do good. Then the question is, “Does doing good include getting involved in interrogations?” Dr. Howe asked.

Even if society is willing, in theory, to say that it will make these sacrifices so that students can be trained to become doctors to heal medical and psychiatric problems and also to save lives by participating in some way in interrogations, “it does not necessarily mean that it should fly, even if most psychiatrists would go along with it. Additional ethical assessment is necessary,” he said.

Contrary to the position taken by key experts, the American Psychological Association's approach to this issue appears to be different. That organization's Presidential Task Force states that psychologists can “serve in the role of supporting an interrogation” and make use of confidential information in medical records of detainees or prisoners to advise interrogators, as long as it is not used to the detriment of the individual's safety and well-being.

The task force's report does warn psychologists working in a national security-related setting that they should “clarify their role in situations where individuals may have an incorrect impression that psychologists are serving in a health care provider role.”

In addition, psychologists should refrain from mixing potentially inconsistent roles with the same individual, in those cases when the roles “could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness. … or otherwise risk exploitation or harm to the person with whom the professional relationship exists.”

In the panel discussion, Dr. Bloche argued that the American Psychological Association's statement “allows for a wholesale breach of confidentiality.”

However, Stephen Behnke, director of ethics for the American Psychological Association, said in an interview that there should be an absolute barrier between work that is treatment related and work related to interrogations.

“Under no circumstances should the two be mixed,” Mr. Behnke said.

He pointed out that his association had provided its task force report to the U.S. government and that training is needed.

But overcoming the obstacle of health care providers serving as consultants to interrogators by creating separate schools or training for each type, “doesn't really address what the real problems are,” Dr. Howe said.

The real problems are determining how humans should treat other humans—and who should decide, he asserted.

WASHINGTON — Detailed ethical codes from professional organizations would help set a clearer path for health professionals to follow on national security-related issues.

That sentiment was expressed by several experts at a recent panel discussion on the medical ethics of military medical professionals' interrogations sponsored by the Center for American Progress.

Active and retired medical officers also think the policy that guides medical personnel in these matters needs to be clarified, Stephen Xenakis, M.D., said at the meeting. Dr. Xenakis, formerly the commanding general of the Southeast Regional Army Medical Command, is now the director of child and adolescent psychiatry at the Psychiatric Institute of Washington.

At Guantanamo Bay and Abu Ghraib prison, mental health professionals, such as psychiatrists and psychologists, are known to have observed interrogations, provided interrogators with the medical records of detainees, and in some cases, developed individualized interrogation plans or provided advice on how best to conduct an interrogation.

These acts have been made public by various documents obtained through military sources, Freedom of Information Act requests, declassification, interviews with witnesses, or testimony (N. Engl. J. Med. 2005;352:3–6; N. Engl. J. Med. 2005;353:6–8).

“The legal barriers are likely to be crossed long before detainees' mental or physical health is implicated, particularly when those detainees are protected by the Geneva Conventions,” Jonathan H. Marks, said at the panel discussion.

“Medical personnel, if they stand by, will be complicit in violations of the Geneva Conventions if they approve of these techniques or fail to intervene,” said Mr. Marks, a barrister who is currently a fellow at Georgetown University Law Center, Washington.

The civilian leadership at the Pentagon has argued that when physicians and other health professionals serve in the interrogation process and other nontherapeutic roles, they are not acting as physicians or health professionals, and medical ethics do not apply, noted M. Gregg Bloche, M.D., a member of the panel. “This is a deeply disturbing argument with little or no precedent elsewhere,” said Dr. Bloche, a law professor at Georgetown.

In previous operations, the Army has worked on the principle of very detailed, exhaustive training for its medical personnel, Dr. Xenakis noted. The current operations lack “clear guidance for what one does when one confronts scenarios of large volumes of detainees who have recently been apprehended, how they will be triaged, how they will be held, how they will be interrogated.”

Dr. Xenakis said he would like to see the American Medical Association and the American Psychiatric Association define the guidance policy on what military medical personnel should and should not be expected to do. Such statements would be affirming to the internal principles and ethics of physicians and other health professionals, he added.

New absolute standards must limit the physician's role in the military to the doctor-patient relationship in which a physician cannot participate in interrogations, he suggested.

Indeed, the APA is in the process of hammering out a position on the role that mental health professionals should play in the interrogation of detainees at Guantanamo Bay and other prison sites around the world, Paul S. Appelbaum, M.D., told this newspaper.

Representatives from several key APA committees met this fall to develop a proposed position. That proposal will then go through a formal chain of approvals, including the APA assembly and the board of trustees, said Dr. Appelbaum, chairman of the APA's Council on Psychiatry and the Law and a former president of the organization.

However, the debate about this issue also needs to take place in the public domain, Edmund G. Howe, M.D., said in an interview.

Dr. Howe, professor of psychiatry and director of the program in ethics at the Uniformed Services University of the Health Sciences, Bethesda, Md., said he would like to see a code in print representing as many military and civilian views as possible.

Codes of ethics “can accomplish all sorts of things by giving general guidelines that most persons find useful and maybe [help them] do better than they would without those guidelines.

The question here is, what are the pluses and minuses of any group's spelling out its particular moral priorities?” Dr. Howe said.

It would be problematic for the military to articulate its moral biases and perspectives and then impose them without outside input, Dr. Howe said. He added that while that might be obvious, it's less obvious that any organization—whether it be the AMA or the APA—also has its own biases and perspectives.

For example, why shouldn't the American Bar Association or a patients' association, for that matter, have its own code? “Is medical expertise tantamount to ethical expertise? No,” Dr. Howe said.

When patients sacrifice their money and personal privacy so that medical students can perform physical exams and develop their skills, society has implicit expectations about what the students will do with the knowledge they gain from encounters with patients. Some would say that there's an implicit promise from the doctor—like the Hippocratic Oath—when the patient is making those sacrifices in order for the doctor to do good. Then the question is, “Does doing good include getting involved in interrogations?” Dr. Howe asked.

Even if society is willing, in theory, to say that it will make these sacrifices so that students can be trained to become doctors to heal medical and psychiatric problems and also to save lives by participating in some way in interrogations, “it does not necessarily mean that it should fly, even if most psychiatrists would go along with it. Additional ethical assessment is necessary,” he said.

Contrary to the position taken by key experts, the American Psychological Association's approach to this issue appears to be different. That organization's Presidential Task Force states that psychologists can “serve in the role of supporting an interrogation” and make use of confidential information in medical records of detainees or prisoners to advise interrogators, as long as it is not used to the detriment of the individual's safety and well-being.

The task force's report does warn psychologists working in a national security-related setting that they should “clarify their role in situations where individuals may have an incorrect impression that psychologists are serving in a health care provider role.”

In addition, psychologists should refrain from mixing potentially inconsistent roles with the same individual, in those cases when the roles “could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness. … or otherwise risk exploitation or harm to the person with whom the professional relationship exists.”

In the panel discussion, Dr. Bloche argued that the American Psychological Association's statement “allows for a wholesale breach of confidentiality.”

However, Stephen Behnke, director of ethics for the American Psychological Association, said in an interview that there should be an absolute barrier between work that is treatment related and work related to interrogations.

“Under no circumstances should the two be mixed,” Mr. Behnke said.

He pointed out that his association had provided its task force report to the U.S. government and that training is needed.

But overcoming the obstacle of health care providers serving as consultants to interrogators by creating separate schools or training for each type, “doesn't really address what the real problems are,” Dr. Howe said.

The real problems are determining how humans should treat other humans—and who should decide, he asserted.

NEW YORK — The notion that low-acuity patients are an important cause of overcrowding in the emergency department is probably not true, Michael J. Schull, M.D., reported at the annual meeting of the Society for Academic Emergency Medicine.

Administrators, politicians, researchers, and physicians often blame low-acuity patients for worsened ED crowding. Plans to reduce ED overcrowding include diverting low-acuity ED patients to places such as fast-track emergent care centers or primary care clinics.

But it is unknown if low-acuity patients are actually responsible for extended lengths of stay for patients with more acute conditions, said Dr. Schull, an emergency physician at the Institute for Clinical Evaluative Sciences at Sunnybrook and Women's College Health Sciences Centre, Toronto.

He and his colleagues analyzed the assumption that low-acuity patients contribute to ED overcrowding by reviewing consecutive 8-hour intervals in an administrative data set that included all visits to all high-volume EDs in Ontario during 2002–2003. Overall, the investigators analyzed 4.1 million visits to 110 EDs (16 teaching and 94 community) that had patient volumes ranging from 13,000 to 81,000 per year.

He classified high-acuity ED patients as those who were admitted to the hospital and low-acuity patients as those who arrived at the ED under their own power, received a score of 4 or 5 on the Canadian Triage & Acuity Scale, and were later discharged. All other ED patients were medium-acuity patients.

A patient's entire length of stay in the ED was credited to the 8-hour interval in which he or she arrived, even if the stay extended into the next interval.

Dr. Schull did not find that the EDs were able to reduce the collective length of stay of medium- and high-acuity patients any faster when fewer low-acuity patients were present. For every new low-acuity patient, the combined length of stay for medium- and high-acuity patients increased by only 0.6 minutes. Each new high-acuity patient increased the total length of stay for medium- and high-acuity patients by 7 minutes.

“It takes about 12 new low-acuity patients to be equivalent to 1 high-acuity patient” in increasing the length of stay of medium- and high-acuity patients, he said.

During a typical 8-hour interval, a median of 16 new low-acuity patients arrived at an ED, resulting in an average increase in the length of stay of medium- and high-acuity patients of 9.7 minutes (4% increase), which is not clinically significant, Dr. Schull said. A median of three new high-acuity patients arrived at an ED during the 8-hour interval, increasing the mean length of stay of medium- and high-acuity patients by 21 minutes (9%).

NEW YORK — The notion that low-acuity patients are an important cause of overcrowding in the emergency department is probably not true, Michael J. Schull, M.D., reported at the annual meeting of the Society for Academic Emergency Medicine.

Administrators, politicians, researchers, and physicians often blame low-acuity patients for worsened ED crowding. Plans to reduce ED overcrowding include diverting low-acuity ED patients to places such as fast-track emergent care centers or primary care clinics.

But it is unknown if low-acuity patients are actually responsible for extended lengths of stay for patients with more acute conditions, said Dr. Schull, an emergency physician at the Institute for Clinical Evaluative Sciences at Sunnybrook and Women's College Health Sciences Centre, Toronto.

He and his colleagues analyzed the assumption that low-acuity patients contribute to ED overcrowding by reviewing consecutive 8-hour intervals in an administrative data set that included all visits to all high-volume EDs in Ontario during 2002–2003. Overall, the investigators analyzed 4.1 million visits to 110 EDs (16 teaching and 94 community) that had patient volumes ranging from 13,000 to 81,000 per year.

He classified high-acuity ED patients as those who were admitted to the hospital and low-acuity patients as those who arrived at the ED under their own power, received a score of 4 or 5 on the Canadian Triage & Acuity Scale, and were later discharged. All other ED patients were medium-acuity patients.

A patient's entire length of stay in the ED was credited to the 8-hour interval in which he or she arrived, even if the stay extended into the next interval.

Dr. Schull did not find that the EDs were able to reduce the collective length of stay of medium- and high-acuity patients any faster when fewer low-acuity patients were present. For every new low-acuity patient, the combined length of stay for medium- and high-acuity patients increased by only 0.6 minutes. Each new high-acuity patient increased the total length of stay for medium- and high-acuity patients by 7 minutes.

“It takes about 12 new low-acuity patients to be equivalent to 1 high-acuity patient” in increasing the length of stay of medium- and high-acuity patients, he said.

During a typical 8-hour interval, a median of 16 new low-acuity patients arrived at an ED, resulting in an average increase in the length of stay of medium- and high-acuity patients of 9.7 minutes (4% increase), which is not clinically significant, Dr. Schull said. A median of three new high-acuity patients arrived at an ED during the 8-hour interval, increasing the mean length of stay of medium- and high-acuity patients by 21 minutes (9%).

NEW YORK — The notion that low-acuity patients are an important cause of overcrowding in the emergency department is probably not true, Michael J. Schull, M.D., reported at the annual meeting of the Society for Academic Emergency Medicine.

Administrators, politicians, researchers, and physicians often blame low-acuity patients for worsened ED crowding. Plans to reduce ED overcrowding include diverting low-acuity ED patients to places such as fast-track emergent care centers or primary care clinics.

But it is unknown if low-acuity patients are actually responsible for extended lengths of stay for patients with more acute conditions, said Dr. Schull, an emergency physician at the Institute for Clinical Evaluative Sciences at Sunnybrook and Women's College Health Sciences Centre, Toronto.

He and his colleagues analyzed the assumption that low-acuity patients contribute to ED overcrowding by reviewing consecutive 8-hour intervals in an administrative data set that included all visits to all high-volume EDs in Ontario during 2002–2003. Overall, the investigators analyzed 4.1 million visits to 110 EDs (16 teaching and 94 community) that had patient volumes ranging from 13,000 to 81,000 per year.

He classified high-acuity ED patients as those who were admitted to the hospital and low-acuity patients as those who arrived at the ED under their own power, received a score of 4 or 5 on the Canadian Triage & Acuity Scale, and were later discharged. All other ED patients were medium-acuity patients.

A patient's entire length of stay in the ED was credited to the 8-hour interval in which he or she arrived, even if the stay extended into the next interval.

Dr. Schull did not find that the EDs were able to reduce the collective length of stay of medium- and high-acuity patients any faster when fewer low-acuity patients were present. For every new low-acuity patient, the combined length of stay for medium- and high-acuity patients increased by only 0.6 minutes. Each new high-acuity patient increased the total length of stay for medium- and high-acuity patients by 7 minutes.

“It takes about 12 new low-acuity patients to be equivalent to 1 high-acuity patient” in increasing the length of stay of medium- and high-acuity patients, he said.

During a typical 8-hour interval, a median of 16 new low-acuity patients arrived at an ED, resulting in an average increase in the length of stay of medium- and high-acuity patients of 9.7 minutes (4% increase), which is not clinically significant, Dr. Schull said. A median of three new high-acuity patients arrived at an ED during the 8-hour interval, increasing the mean length of stay of medium- and high-acuity patients by 21 minutes (9%).

STOCKHOLM — Individuals who carry the apolipoprotein E ϵ4 allele that increases the risk of developing Alzheimer's disease may lower their risk to that of a noncarrier through regular exercise, moderate fat intake, and low alcohol consumption, reported Tiia Ngandu at the 12th Congress of the International Psychogeriatric Association.

Ms. Ngandu and her associates studied 1,449 Finnish people who participated in the longitudinal, population-based Cardiovascular Risk Factors, Aging, and Dementia study (CAIDE) in 1972, 1977, 1982, or 1987. After an average follow-up of 21 years, the participants were aged 65–79 years when they were re-examined in 1998.

Based on questions answered at midlife, active individuals (exercised at least twice per week) who carried the ϵ4 allele had a significantly lower likelihood of developing Alzheimer's disease (AD) than sedentary carriers, said Ms. Ngandu, a doctoral student at the Aging Research Center at the Karolinska Institute, Stockholm.

Intake of polyunsaturated fatty acids did not alter the odds of developing AD in carriers, but high intake of saturated fatty acids was associated with significantly greater odds of AD in carriers, compared with a low intake.

Carriers who frequently consumed alcohol had a significantly higher likelihood of developing AD than carriers who drank infrequently or never.

None of the lifestyle factors reduced the risk of AD in noncarriers, she noted.

People with a parent with late-onset Alzheimer's disease may undergo genotyping for apolipoprotein E. A positive finding is not diagnostic of Alzheimer's disease, even in a symptomatic patient.

STOCKHOLM — Individuals who carry the apolipoprotein E ϵ4 allele that increases the risk of developing Alzheimer's disease may lower their risk to that of a noncarrier through regular exercise, moderate fat intake, and low alcohol consumption, reported Tiia Ngandu at the 12th Congress of the International Psychogeriatric Association.

Ms. Ngandu and her associates studied 1,449 Finnish people who participated in the longitudinal, population-based Cardiovascular Risk Factors, Aging, and Dementia study (CAIDE) in 1972, 1977, 1982, or 1987. After an average follow-up of 21 years, the participants were aged 65–79 years when they were re-examined in 1998.

Based on questions answered at midlife, active individuals (exercised at least twice per week) who carried the ϵ4 allele had a significantly lower likelihood of developing Alzheimer's disease (AD) than sedentary carriers, said Ms. Ngandu, a doctoral student at the Aging Research Center at the Karolinska Institute, Stockholm.

Intake of polyunsaturated fatty acids did not alter the odds of developing AD in carriers, but high intake of saturated fatty acids was associated with significantly greater odds of AD in carriers, compared with a low intake.

Carriers who frequently consumed alcohol had a significantly higher likelihood of developing AD than carriers who drank infrequently or never.

None of the lifestyle factors reduced the risk of AD in noncarriers, she noted.

People with a parent with late-onset Alzheimer's disease may undergo genotyping for apolipoprotein E. A positive finding is not diagnostic of Alzheimer's disease, even in a symptomatic patient.

STOCKHOLM — Individuals who carry the apolipoprotein E ϵ4 allele that increases the risk of developing Alzheimer's disease may lower their risk to that of a noncarrier through regular exercise, moderate fat intake, and low alcohol consumption, reported Tiia Ngandu at the 12th Congress of the International Psychogeriatric Association.

Ms. Ngandu and her associates studied 1,449 Finnish people who participated in the longitudinal, population-based Cardiovascular Risk Factors, Aging, and Dementia study (CAIDE) in 1972, 1977, 1982, or 1987. After an average follow-up of 21 years, the participants were aged 65–79 years when they were re-examined in 1998.

Based on questions answered at midlife, active individuals (exercised at least twice per week) who carried the ϵ4 allele had a significantly lower likelihood of developing Alzheimer's disease (AD) than sedentary carriers, said Ms. Ngandu, a doctoral student at the Aging Research Center at the Karolinska Institute, Stockholm.

Intake of polyunsaturated fatty acids did not alter the odds of developing AD in carriers, but high intake of saturated fatty acids was associated with significantly greater odds of AD in carriers, compared with a low intake.

Carriers who frequently consumed alcohol had a significantly higher likelihood of developing AD than carriers who drank infrequently or never.

None of the lifestyle factors reduced the risk of AD in noncarriers, she noted.

People with a parent with late-onset Alzheimer's disease may undergo genotyping for apolipoprotein E. A positive finding is not diagnostic of Alzheimer's disease, even in a symptomatic patient.

STOCKHOLM — Clinicians shy away from disclosing a diagnosis of mild cognitive impairment and its potential to convert to Alzheimer's disease.

They also differ in how they word the disclosure when they opt to share the diagnosis and prognosis with the patient and relatives. For their part, families may not want patients to know when they have been diagnosed with Alzheimer's disease, according to reports presented at the 12th Congress of the International Psychogeriatric Association.

“In dementia, disclosure is not common clinical practice”—only about 15% of professionals disclose the diagnosis to patients—“but there seems to be a trend toward more openness about the diagnosis,” said Els Derksen, R.N., a researcher at the Alzheimer's center at St. Radboud University Medical Center, Nijmegen, the Netherlands. But in contrast to several studies of disclosing a diagnosis of dementia, no studies have been published about disclosing a diagnosis of mild cognitive impairment (MCI).

Ms. Derksen discussed the responses of physicians who completed an optional appendix to a questionnaire that was a part of the European DESCRIPA (Development of Screening Guidelines and Diagnostic Criteria for Predementia Alzheimer's Disease) multicenter study. The study included patients with suspected MCI.

In discussions with 101 patients with MCI or possible early dementia, physicians told 28% that they had MCI, 62% that they had abnormal memory or cognitive problems, 4% that they had worrisome symptoms or depression plus memory problems, 3% that they had normal memory problems or forgetfulness, 2% that they had amnestic symptoms, and 1% that they had mixed and vascular dementia.

Among 100 patients who received information about their prognosis, physicians told 4% nothing, 18% that the prognosis was unknown or uncertain, 20% that the condition probably would remain stable, 10% that it probably would progress, and 66% that follow-up would be indicated. (The percentages do not add to 100% because follow-up was included with other information for some patients.)

When physicians were asked to describe their use of the term Alzheimer's disease in their interactions with a total of 80 patients, they reported that they did not use the term at all in 23%. Physicians told 72% that they could possibly convert to Alzheimer's disease. They told 4% of the patients that they had Alzheimer's disease or predementia, and 1% that Alzheimer's was not present or detected.

In nearly all instances, the same information about diagnosis, prognosis, and specific use of the term Alzheimer's disease was given to patients' families.

Alzheimer's disease in its predementia stage was suspected in 77 of 101 patients. A physician's decision to inform a patient of the diagnosis was most often guided by the patient's wish to know, a belief in shared decision making between physician and patient, and initiation of medication.

In a separate study, family members of patients with Alzheimer's indicated that they did not wish to reveal the diagnosis to patients primarily because of a concern for causing anxiety and depression.

Filip Bouckaert, M.D., of the department of old age psychiatry at University Centre St. Jozef, Kortenberg, Belgium, interviewed 50 family members of outpatients with Alzheimer's disease and 50 family members of inpatients with the disease. Their results, reported during a poster session at the congress, showed that 57% did not want the patient to be told the diagnosis; this included 42% of family members of outpatients and 72% of family members of inpatients.

Half of family members who did not want the patients to know about the diagnosis cited the possibility of causing anxiety or depression as the main reason not to tell. Similarly, half of those who thought the patient should be told said that his or her right to know was the primary reason to tell the patient the diagnosis.

More family members approved of the disclosure of diagnosis in patients with mild dementia (86%) than in those with moderate (39%) or severe (31%) dementia.

Despite the wish by most family members not to disclose the diagnosis to their affected relatives, 90% of family members wanted to be told their diagnosis if they developed Alzheimer's disease.

STOCKHOLM — Clinicians shy away from disclosing a diagnosis of mild cognitive impairment and its potential to convert to Alzheimer's disease.

They also differ in how they word the disclosure when they opt to share the diagnosis and prognosis with the patient and relatives. For their part, families may not want patients to know when they have been diagnosed with Alzheimer's disease, according to reports presented at the 12th Congress of the International Psychogeriatric Association.

“In dementia, disclosure is not common clinical practice”—only about 15% of professionals disclose the diagnosis to patients—“but there seems to be a trend toward more openness about the diagnosis,” said Els Derksen, R.N., a researcher at the Alzheimer's center at St. Radboud University Medical Center, Nijmegen, the Netherlands. But in contrast to several studies of disclosing a diagnosis of dementia, no studies have been published about disclosing a diagnosis of mild cognitive impairment (MCI).

Ms. Derksen discussed the responses of physicians who completed an optional appendix to a questionnaire that was a part of the European DESCRIPA (Development of Screening Guidelines and Diagnostic Criteria for Predementia Alzheimer's Disease) multicenter study. The study included patients with suspected MCI.

In discussions with 101 patients with MCI or possible early dementia, physicians told 28% that they had MCI, 62% that they had abnormal memory or cognitive problems, 4% that they had worrisome symptoms or depression plus memory problems, 3% that they had normal memory problems or forgetfulness, 2% that they had amnestic symptoms, and 1% that they had mixed and vascular dementia.

Among 100 patients who received information about their prognosis, physicians told 4% nothing, 18% that the prognosis was unknown or uncertain, 20% that the condition probably would remain stable, 10% that it probably would progress, and 66% that follow-up would be indicated. (The percentages do not add to 100% because follow-up was included with other information for some patients.)

When physicians were asked to describe their use of the term Alzheimer's disease in their interactions with a total of 80 patients, they reported that they did not use the term at all in 23%. Physicians told 72% that they could possibly convert to Alzheimer's disease. They told 4% of the patients that they had Alzheimer's disease or predementia, and 1% that Alzheimer's was not present or detected.

In nearly all instances, the same information about diagnosis, prognosis, and specific use of the term Alzheimer's disease was given to patients' families.

Alzheimer's disease in its predementia stage was suspected in 77 of 101 patients. A physician's decision to inform a patient of the diagnosis was most often guided by the patient's wish to know, a belief in shared decision making between physician and patient, and initiation of medication.

In a separate study, family members of patients with Alzheimer's indicated that they did not wish to reveal the diagnosis to patients primarily because of a concern for causing anxiety and depression.

Filip Bouckaert, M.D., of the department of old age psychiatry at University Centre St. Jozef, Kortenberg, Belgium, interviewed 50 family members of outpatients with Alzheimer's disease and 50 family members of inpatients with the disease. Their results, reported during a poster session at the congress, showed that 57% did not want the patient to be told the diagnosis; this included 42% of family members of outpatients and 72% of family members of inpatients.

Half of family members who did not want the patients to know about the diagnosis cited the possibility of causing anxiety or depression as the main reason not to tell. Similarly, half of those who thought the patient should be told said that his or her right to know was the primary reason to tell the patient the diagnosis.

More family members approved of the disclosure of diagnosis in patients with mild dementia (86%) than in those with moderate (39%) or severe (31%) dementia.

Despite the wish by most family members not to disclose the diagnosis to their affected relatives, 90% of family members wanted to be told their diagnosis if they developed Alzheimer's disease.

STOCKHOLM — Clinicians shy away from disclosing a diagnosis of mild cognitive impairment and its potential to convert to Alzheimer's disease.

They also differ in how they word the disclosure when they opt to share the diagnosis and prognosis with the patient and relatives. For their part, families may not want patients to know when they have been diagnosed with Alzheimer's disease, according to reports presented at the 12th Congress of the International Psychogeriatric Association.

“In dementia, disclosure is not common clinical practice”—only about 15% of professionals disclose the diagnosis to patients—“but there seems to be a trend toward more openness about the diagnosis,” said Els Derksen, R.N., a researcher at the Alzheimer's center at St. Radboud University Medical Center, Nijmegen, the Netherlands. But in contrast to several studies of disclosing a diagnosis of dementia, no studies have been published about disclosing a diagnosis of mild cognitive impairment (MCI).

Ms. Derksen discussed the responses of physicians who completed an optional appendix to a questionnaire that was a part of the European DESCRIPA (Development of Screening Guidelines and Diagnostic Criteria for Predementia Alzheimer's Disease) multicenter study. The study included patients with suspected MCI.

In discussions with 101 patients with MCI or possible early dementia, physicians told 28% that they had MCI, 62% that they had abnormal memory or cognitive problems, 4% that they had worrisome symptoms or depression plus memory problems, 3% that they had normal memory problems or forgetfulness, 2% that they had amnestic symptoms, and 1% that they had mixed and vascular dementia.

Among 100 patients who received information about their prognosis, physicians told 4% nothing, 18% that the prognosis was unknown or uncertain, 20% that the condition probably would remain stable, 10% that it probably would progress, and 66% that follow-up would be indicated. (The percentages do not add to 100% because follow-up was included with other information for some patients.)

When physicians were asked to describe their use of the term Alzheimer's disease in their interactions with a total of 80 patients, they reported that they did not use the term at all in 23%. Physicians told 72% that they could possibly convert to Alzheimer's disease. They told 4% of the patients that they had Alzheimer's disease or predementia, and 1% that Alzheimer's was not present or detected.

In nearly all instances, the same information about diagnosis, prognosis, and specific use of the term Alzheimer's disease was given to patients' families.

Alzheimer's disease in its predementia stage was suspected in 77 of 101 patients. A physician's decision to inform a patient of the diagnosis was most often guided by the patient's wish to know, a belief in shared decision making between physician and patient, and initiation of medication.

In a separate study, family members of patients with Alzheimer's indicated that they did not wish to reveal the diagnosis to patients primarily because of a concern for causing anxiety and depression.

Filip Bouckaert, M.D., of the department of old age psychiatry at University Centre St. Jozef, Kortenberg, Belgium, interviewed 50 family members of outpatients with Alzheimer's disease and 50 family members of inpatients with the disease. Their results, reported during a poster session at the congress, showed that 57% did not want the patient to be told the diagnosis; this included 42% of family members of outpatients and 72% of family members of inpatients.

Half of family members who did not want the patients to know about the diagnosis cited the possibility of causing anxiety or depression as the main reason not to tell. Similarly, half of those who thought the patient should be told said that his or her right to know was the primary reason to tell the patient the diagnosis.

More family members approved of the disclosure of diagnosis in patients with mild dementia (86%) than in those with moderate (39%) or severe (31%) dementia.

Despite the wish by most family members not to disclose the diagnosis to their affected relatives, 90% of family members wanted to be told their diagnosis if they developed Alzheimer's disease.

NEW YORK — A single intramuscular injection of methylprednisolone failed to relieve idiopathic, nontraumatic, low back pain any better than a placebo in a small, double-blind, randomized trial.

Corticosteroids previously had not been tested in a randomized, controlled trial for acute low back pain in young adult patients in the emergency department, Benjamin W. Friedman, M.D., said at the annual meeting of the Society for Academic Emergency Medicine.

In the trial, the pain level of 44 patients who received 160 mg of the methylprednisolone acetate did not improve significantly more than the pain level of 43 patients who received a saline injection.

On a 1–10 scale—with mild pain rated 1 and excruciating pain, rated 10—pain scores shifted from 7.6 at baseline in the corticosteroid group to 3.5 at 1 week and 2.9 at 1 month.

In the placebo group, scores improved from 8.1 at baseline to 3.3 at 1 week and 2.3 at 1 month, reported Dr. Friedman of the Montefiore Medical Center, New York.

After 1 month, similar percentages of patients in the corticosteroid and placebo groups reported having had low back pain in the previous 24 hours

All of the patients were 50 years of age or younger (with an average age of 36 years) and reported low back pain for 1 week or less.

NEW YORK — A single intramuscular injection of methylprednisolone failed to relieve idiopathic, nontraumatic, low back pain any better than a placebo in a small, double-blind, randomized trial.

Corticosteroids previously had not been tested in a randomized, controlled trial for acute low back pain in young adult patients in the emergency department, Benjamin W. Friedman, M.D., said at the annual meeting of the Society for Academic Emergency Medicine.

In the trial, the pain level of 44 patients who received 160 mg of the methylprednisolone acetate did not improve significantly more than the pain level of 43 patients who received a saline injection.

On a 1–10 scale—with mild pain rated 1 and excruciating pain, rated 10—pain scores shifted from 7.6 at baseline in the corticosteroid group to 3.5 at 1 week and 2.9 at 1 month.

In the placebo group, scores improved from 8.1 at baseline to 3.3 at 1 week and 2.3 at 1 month, reported Dr. Friedman of the Montefiore Medical Center, New York.

After 1 month, similar percentages of patients in the corticosteroid and placebo groups reported having had low back pain in the previous 24 hours

All of the patients were 50 years of age or younger (with an average age of 36 years) and reported low back pain for 1 week or less.

NEW YORK — A single intramuscular injection of methylprednisolone failed to relieve idiopathic, nontraumatic, low back pain any better than a placebo in a small, double-blind, randomized trial.

Corticosteroids previously had not been tested in a randomized, controlled trial for acute low back pain in young adult patients in the emergency department, Benjamin W. Friedman, M.D., said at the annual meeting of the Society for Academic Emergency Medicine.

In the trial, the pain level of 44 patients who received 160 mg of the methylprednisolone acetate did not improve significantly more than the pain level of 43 patients who received a saline injection.

On a 1–10 scale—with mild pain rated 1 and excruciating pain, rated 10—pain scores shifted from 7.6 at baseline in the corticosteroid group to 3.5 at 1 week and 2.9 at 1 month.

In the placebo group, scores improved from 8.1 at baseline to 3.3 at 1 week and 2.3 at 1 month, reported Dr. Friedman of the Montefiore Medical Center, New York.

After 1 month, similar percentages of patients in the corticosteroid and placebo groups reported having had low back pain in the previous 24 hours

All of the patients were 50 years of age or younger (with an average age of 36 years) and reported low back pain for 1 week or less.